Reading Failure and the Learning-Dyslabeled Child

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PEDIATRICS Vol. 63 No. 5 May 1979

817

related directly to safety packaging during the

study period 1968 to 1974, most likely are due to a

decrease in ingestion of fatal quantities of adult

aspirin products and methyl salicylate. Note that

the most significant decrease occurred in 1973,

following the regulatory requirements for safety

packaging of adult aspirin and methyl salicylate.

A case-by-case analysis of the reported deaths would be helpful in clarifying the relationship of safety packaging to mortality from the various salicylates. It would also give greater resolution

regarding the hazards of salicylate therapy for

young children.

Another problem that interferes with

interpre-tation of mortality reports from the National

Center for Health Statistics (NCHS) is that deaths

from aspirin are not reported as a separate

category. Aspirin is grouped with other salicylates

to include aspirin-containing products and

methyl salicylates. Furthermore, NCHS does not

identify accidental deaths from these products as

distinct from therapeutic misadventures. Thera-peutic overdose may be an important factor that

niust be investigated and clarified if prevention

programs are to be developed which will produce

further significant decreases in mortality rates.

This study also brings out a need for developing

a sampling process for reports of accidental

poisoning that will produce more sensitive and

reliable statistics as a measure of change. The

National Clearing House for Poison Control

Centers provides a hodge-podge reporting system

that needs a complete revision if the data is to be

used as an accurate reflection of poison incidents

in the United States. Although the exactness of

the decreases in poisoning of children during the

study period is questionable, the trend is

undeni-ably down. Safety packaging has been a signifi-cant factor in this decline.

There are still a number of questions

unan-swered in addition to those mentioned by Clarke

and Walton. How did the children who were

poisoned gain access to the aspirin? Did they

actually open the packages? Were the closures

defective or perhaps not closed properly? Was

the aspirin in the original container or perhaps

transferred to an unsafe container? What were

the ages of the children who opened closures

versus those who gained access to opened or improperly secured containers? What types of safety closures seemed most effective? What

changes have there been in hospitalizations and

visits to emergency rooms? What are the compar-ative numbers of safety and nonsafety packages for aspirin products in homes where young chil-dren have access? Do children see safety packages

as a challenge or an indication that the contents

may be harmful? Do adults selectively use one

form of safety package more appropriately than

another? These questions and more were not

answered and many were not addressed in the

study. The answers are needed to sort out factors that support or decrease the value of specific safety packaging to deter poisoning of young children.

Although not all of the demographic data needed to determine the true effectiveness of

safety packaging on “unauthorized” aspirin

inges-tion by young children in the United States is available at this time, those of us who operate poison centers and have hospital facilities for children will attest that the problem has

decreased quite significantly during the past ten

years. The bottom line is fewer emergency room

visits and fewer hospitalizations for treatment of

aspirin ingestions. It would appear that safety packaging is a passive immunization process that, when used properly, will help protect the young child from poisoning.

ROBERT

G.

SCHERZ,

M.D.

Mary Bridge Children’s Health Center

311 South L Street Tacoma, WA 98405

REFERENCE

1. Howes DR: An Evaluation of time Effectiveness of Child-Resistant Packaging. Washington, DC, Office of Strategic Planning, Consumer Product Safety Commission, May 1978.

Reading

Failure

and

the

Learning-Dyslabeled

Child

It is easier to be an adult than a child. In middle life, there are multiple options for the consumma-tion of strengths; vocational and avocational niches offer refuge to the most divergent of functional profiles. During childhood, academic and social demands are rigid, allowing for little or no eccentricity, and sometimes alienating those

youth who are destined to become better adults

than children. A child may be made to feel guilty if he or she does not demonstrate high levels of attainment or working capacity in language arts, quantitative thinking, motor activities, and social adaptability. There is the expectation that a

young brain can be a “perfect machine.”

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818

READING FAILURE

Expectations are conditioned by cultural and

economic exigencies. A high level of talent with

bow and arrow (largely a visual-motor activity) will not reap the rewards brought by rapid word

finding and verbal comprehension. Those with

the latter are likely to become bosses. In other cultures, the opposite might be true. Dr. Snyder’s special article in this issue of Pediatrics (page 791) suggests strongly that certain children have “the

right not to read.” A more general statement

might be that they have the right to be authentic, to allow their uniquely wired neural circuits to operate at their own pace, and to accomplish the

tasks for which their systems were designed. This

is a most defensible stance. It forces us to question assumptions underlying the adult’s incessant

efforts to change children. It encourages us to

recognize, respect, and preserve individual

varia-tion. The position is weakened seriously by limi-tations in our knowledge of child development. We cannot differentiate style from handicap

clearly. The young brain does not come with an

owner’s manual! We have no way of ascertaining

whether a particular central nervous system is being misused or whether it is in need of repair. If

an individualized style is extremely discrepant

from societal expectations, the resultant

unhappi-ness and human tragedy may indeed constitute a “handicap.”

The term dyslexia connotes a miswired system.

Most educators and physicians have inferred from

this diagnosis that work needs to be done to repair

specific defects in information processing. As Dr.

Snyder notes, most clinicians and investigators are recognizing the misapplication of such terminolo-gy. Children who fail to read “at grade level”

reflect a heterogenous group of disorders,

mal-adaptive styles, variations on normalcy, and

specific teaching disabilities. It is clear that this

label, like so many others, is potentially

danger-otis and offers little relevance with regard to etiology, prognosis, or therapeutic direction.

Individual children with reading failure may

fall into one or more subgroups, each of which contains subcategories. Among these one might include the following:

1. Children with specific “handicaps of

infor-ination processing. This might include

youngsters with visual-spatial disorienta-tion; language disabilities; significant

short-or long-term memory problems; deficits of

temporal-sequential organization; and

diffi-culties with higher order conceptual

func-tions such as rule application, abstraction,

and inferential reasoning. Weaknesses in

one or more of these areas may range from

subtle to incapacitating. Individual children

may show one or more of these deficits in a substrate of unique strengths and

prefer-ences.

2. Some children with reading problems may

have maladaptive patterns ofselective

atten-tion. Difficulties with concentration or focus may impede the acquisition of reading skills. In some cases, this may be accompanied by other impairments, such as impulsivity, task impersistence, easy fatigability, distractibili-ty, and poorly modulated activity.

3. Some youngsters may have difficulty

read-ing because of particularly strong learning

styles or orientations. For example, such

specialization might facilitate quantitative thinking.

4. There may be a group of children who acquire academic skills but only at their own

pace. Dr. Snyder points out that these youngsters will learn to read (ultimately) with or without specialized intervention. 5. Some children have difficulty learning

because of disruptive

home

and school

expe-riences. Those who are depressed or preoc-cupied with emotional turmoil and chronic feelings of inadequacy may be distracted from learning.

6.

Socioeconomic and cultural factors may be

associated with reading failure. In some

cases, a lack of academic motivation and learning incentive decelerates the

acquisi-tion of reading skills.

7. Inevitably, some children must occupy the

bottom of every curve. But, then, why have

curves?

Dr. Snyder’s admonitions may be relevant only

for certain subgroups. The problem is that the

diagnostic process is not well enough developed

to make such determinations unequivocably.

Moreover, the technology is not in place to answer certain fundamental questions: Which children will improve spontaneously? Who is actually underachieving? Who is most likely to benefit from intervention? Who is handicapped and who is stylistically specialized? Who is some-how destined to be at the lower end of the reading curve?

Who

will develop a severe learning inhibi-tion while struggling to learn? Studies of the natural history of reading failure have suffered from the lack of a taxonomy or system of classifi-cation. This makes the rigorous study of specific intervention difficult to replicate. Dr. Snyder has

selected reports that suggest the futility of

inter-vention. However, one can also cite investigations demonstrating the efficacy of cognitive interven-tions.”2 The final verdict is not yet in.

One needs to weigh the advantages and

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PEDIATRICS Vol. 63 No. 5 May 1979

819

ties of reading intervention programs. As Dr.

Snyder notes, when they take a toll on the child

emotionally, they are undesirable. On the other hand, some investigators have commented on the

psychotherapuetic benefits of individualized

edu-cational support.’ One also needs to consider carefully the “ripple effects” of delayed skill acquisition. Low self-esteem, depression, social failure, somatic symptoms, and withdrawal are all complications of mastery deprivation. Academic

lags have been associated with major

psychopa-thology, including delinquent antisocial behav-ior’

The child who becomes a nonreader may have seriously limited options in our culture. Do we have the “right” to impose early constriction of opportunity?

Concerted investigation is needed to refine the clinical phenomenology of reading failure, and then to evaluate specific interventions. While awaiting technological strides, the only morally justifiable stance is one of moderation: We need to teach to strengths. We must recognize and nurture individual styles. We need to give serious

consideration to the right not to read (or at least

the right not to read yet). We also need to recognize rights in other academic areas,

espe-cially the rig/mt not to write. For the school-age

child, a central mission is the avoidance of humil-iation. Our programs must help children to save

face, to sustain a respectable level of self-esteem,

and at the same time to develop optimally and with authenticity. We must strike a balance between strengthening weaknesses and devel-oping existing assets. Parents, educators, and pediatricians all need to work in concert to help children thrive functionally. The challenge is to accept and foster cognitive heterogeneity in a culture whose childhood standards, and the educational institutions they spawn, are ironically uniform.

Boston, MA 02115

MELVIN

D.

LEVINE,

M.D.

Division of Ambulatory Pediatrics,

Children’s Hospital Medical Center

REFERENCES

1. Arnold L, Barnehey N, McManus J, et al: Prevention by specific perceptual remediation for vulnerable first graders. Arch Gen Psychiatry 34: 1279, 1977. 2. Wilson 5, Harris C, Harris M: Effects of an auditory

perceptual program on reading performance. I Learn Disabil 9:670, 1976.

3. de Hirsch K: Interactions between educational therapist amid child. Bull Orton Soc 27:88, 1977.

4. Hogenson D: Reading failure and juvenile delinquency. Bull Orton Soc 24:164, 1974.

5. Mauser A: Learning disabilities and delinquent youths.

Acad Ther 9:389, 1974.

Pediatricians

and

Pediatric

Nurse

Practitioners/Associates:

Growth

of

Collegial

Relationships

From my vantage point as president of the

National Association of Pediatric Nurse

Asso-ciates and Practitioners (NAPNAP) during the

years 1975-1978, I have had an opportunity to

observe and participate in the “growth and devel-opment” of professional and interpersonal rela-tionships between pediatricians and pediatric nurse practitioners/associates (PNP/As).

Historically, the specialty of pediatrics has

taken a leadership role in areas related to

consum-er advocacy and the implementation of change: as

primary care providers, emphasizing health education and maintenance, prevention, guid-ance and counseling; as citizens of the larger

community, supporting screening and preventive health programs, encouraging development of needed health and educational services for chil-dren and their families, and influencing political/

social systems to affect change.

It was not surprising, therefore, that pediatrics took a leadership role over ten years ago, when the nurse practitioner was conceptualized as a means of increasing the accessibility to and avail-ability of primary health care services. During

those ten years we have heard various warnings,

accusations, and attempts at intimidation from

within and without the professions of nursing and

medicine. Regarding the nurse practitioner

move-ment, these have included

-Usurpation of the physician’s role

-Development of a second-class system of care

-Fragmentation of care by nurse practitioners

establishing independent practices

-Lack of consumer /physician /nurse accept-ance

-Lower quality of care delivered

-Uncontrolled proliferation of various

catego-ries of “physician extenders’ or ‘nurse

expan-ders”

-Higher health care costs

-Attempts by nurses to gain control of medi-cine as well as nursing

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1979;63;817

Pediatrics

Melvin D. Levine

Reading Failure and the Learning-Dyslabeled Child

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1979;63;817

Pediatrics

Melvin D. Levine

Reading Failure and the Learning-Dyslabeled Child

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